Africa: Rolling Back Malaria?

Editor's Note

The World Malaria Report 2005, a new comprehensive report released
yesterday by the World Health Organization and UNICEF, clearly lays
out the strategies needed to fight malaria, which kills at least
one million people a year. But despite claiming progress in more
widespread adoption of these strategies, the report also
acknowledges that these measures are only beginning to have an
effect. More skeptical observers, such as the medical journal The
Lancet in an April 25 editorial, say that lack of resources and
lack of capacity for implementation have in fact crippled the war
against malaria.

Strategies documented as successful include switching to more
effective (and more expensive) artemesinin-based drugs to replace
older ineffective drugs, massive distribution of insecticidetreated
bednets, and systematic indoor spraying of low-dose
insecticides. But funding is only running at some $600 million a
year, compared to a need for approximately $3.2 billion a year.
Production of the new drugs is not meeting demand. And
environmental concerns have curbed donor support for indoor
spraying, although it has proved particularly effective in South Africa,
Swaziland, and southern Mozambique (seehttp://www.malaria.org.za/Seacat/seacat.html).

First global report on efforts to roll back malaria highlights
progress and challenges

Burden of malaria still worst in Africa, but prevention and
treatment reaching more people

Joint media release WHO/UNICEF

May 3, 2005

More people are accessing prevention and treatment services for
malaria, sparking hope that the number of people who become sick
and die from malaria will begin to decline. However, challenges
remain to reduce the burden of the disease which still kills one
million people every year, most of those in Africa, according to
the 2005 World Malaria Report.

The report, released today by the World Health Organization (WHO)
and the United Nations Children's Fund (UNICEF), finds that
progress has been made in preventing and treating malaria since
2000. It finds that more countries are introducing the newest
medicines to treat malaria, and that more people are receiving
long-lasting insecticide-treated mosquito nets through innovative
new programmes. The report analyzes malaria data collected through
2004 and represents the most comprehensive effort ever made to
present the available evidence on malaria worldwide.

"Many countries are moving forward with malaria control programmes,
and even those with limited resources and a heavy malaria burden
now have a better opportunity to gain ground against this disease,"
said Dr LEE Jong-wook, Director-General of WHO. "However, proven
interventions such as insecticide-treated nets, and the latest
artemisinin-based combination therapies must reach many more people
before we can have a real impact on malaria."

Due to the difficulties involved in gathering reliable information
about malaria in most affected countries and because those
countries have intensified their efforts only in the past few years
it is too soon to measure the impact on illness and death of the
recent expansion of malaria control strategies, the report states.
A measurable effect should become apparent about three years after
widespread implementation.

A number of countries are now engaged in intense antimalarial
campaigns. In particular, more and more people are protected with
insecticide-treated nets - a highly effective method of malaria
prevention. In Africa, all countries reporting on nets collectively
had a 10-fold increase in the number of insecticide-treated nets
distributed over the last three years.

After a 2003 campaign to distribute treated nets in five districts
of Zambia at least 80% of children under five were sleeping under
the nets. A similar campaign across Togo in December 2004 succeeded
in raising the overall percentage of households owning at least one
treated net from 8% to 62%. ...

Countries where the former mainstays of malaria treatment, such as
chloroquine, are no longer effective are also moving forward on new
therapies. Since 2001, 42 malaria-endemic countries, 23 of them in
Africa, have adopted artemisinin-based combination therapies
recommended by WHO. These are the latest generation of antimalarial
medicines and the most effective treatment against falciparum
malaria, the deadliest form of the disease. An additional 14
countries are in the process of changing their malaria treatment
policy and 22 have embarked on home-care programmes which enable
families and other care-givers to manage malaria.

The recent shortage of artemisinin-based combination therapies has
hindered efforts to reduce the impact of the disease, but
sufficient supplies to meet demand are expected to be available by
the end of 2005, thanks to the combined efforts of UN agencies,
other multilateral agencies, non-profit groups and corporations
working together under the umbrella of the Roll Back Malaria
Partnership.

The report finds that in 2003, some 350 to 500 million people
worldwide became ill with malaria a slight revision of the estimate
of 300 to 500 million annual cases that WHO has used since 2000.
The reasons for this difference are advances in data collection
methods and increases in the world's population. ... A major
obstacle to achieving that goal [of halving the burden of malaria
by 2010], the report explains, is a lack of funds. The report
estimates that US$ 3.2 billion per year is needed to effectively
combat malaria in the 82 countries with the highest disease burden.
This year, US$ 600 million was made available for global malaria
control. WHO and UNICEF welcome the recent World Bank announcement
of its plan to commit US$ 500 million to US$ 1 billion over the
next five years, which will help more people get access to
essential malaria prevention and treatment.

A 5-minute briefing on the World Malaria Report 2005 from WHO and
UNICEF

During the past 5 years real progress has been made in scaling up
malaria control and prevention efforts Over 3 billion people live
under the threat of malaria. It kills over a million each year --
mostly children. But the means to turn this tragedy into a global
success story could now be made available to those in need.

Malaria. A disease so deadly it can kill within hours. And so
prevalent that in some parts of the world there is barely a child
who has not suffered by the time of his or her first birthday.
Malaria kills over a million each year and some 3.2 billion people
living in 107 countries or territories are at risk. But malaria is
a curable disease. It is also a preventable disease.

The World Malaria Report 2005 represents the most comprehensive
effort ever made to present the available evidence on malaria all
around the globe. And it shows that during the past 4 or 5 years
real progress has been made in the battle against this most
devastating disease. For while overall trends are still hard to
prove, the World Malaria Report 2005 presents clear evidence of
successful control efforts that are having an impact on malaria in
a large number of countries and territories throughout the world.

Rolling back malaria

A generation ago hopes were high that malaria could be eradicated.
But the 1980s and early 1990s saw a tragic reversal of fortunes.
The disease gathered new strength as the parasites developed
resistance to the most commonly used antimalarial drugs, and the
mosquitoes became resilient to insecticides. Economic upheaval,
armed conflicts and complex emergencies also caused the breakdown
of control programmes and the collapse of local primary health
services. Determination and funds to fight the disease dried up and
malaria once again tightened its grip on the poor and the
vulnerable. In some parts of rural Africa south of the Sahara,
child deaths from malaria increased by up to twofold during the
1990s while deaths from other causes were falling. Malaria also
re-emerged in several Central Asian and Eastern European countries
and in South-East Asia.

In response the Roll Back Malaria (RBM) Partnership was launched in
1998 by the World Health Organization (WHO), the United Nations
Children's Fund (UNICEF), the United Nations Development Programme
(UNDP) and the World Bank to bring together major stakeholders in
the global fight against malaria. These include governments of
malaria-endemic countries, donor governments, international

In the year 2000, African countries committed themselves to a
series of malaria control targets to be reached by the end of 2005,
chiefly protection through the use of ITNs for 60% of the people at
highest risk and intermittent preventive treatment for 60% of
pregnant women. Some countries have been able to reach or even
exceed some of the targets. Most remaining countries are now poised
to begin scaling up antimalarial efforts. A total of 23 African
countries are now using the new and effective drugs (ACTs) and 22
have adopted the RBM-recommended strategy of home management of
malaria for children under 5 years of age.

The number of ITNs distributed has increased 10-fold during the
past 3 years in over 14 African countries. And surveys have shown
remarkable increases in ITN coverage for children under 5 years of
age in countries such as Eritrea and Malawi. But death rates are
still high among those who fall ill and the vast majority of the
death toll is among children under the age of 5. ...

Over 80% of malaria deaths occur in Africa where around 66% of the
population are thought to be at risk. In contrast, less than 15% of
the global total of malaria deaths occurs in Asia (including
Eastern Europe), despite the fact that an estimated 49% of the
people in this region are living under threat from the disease. In
the Americas 14% of the population are at risk, but the region sees
only a tiny fraction of global malaria-related deaths.

As these figures make clear, malaria exacts its heaviest toll on
the African continent. Chiefly there are two explanations. First,
the climate and ecology of tropical Africa provide ideal conditions
for Anopheles gambiae the most efficient of the mosquitoes carrying
the malaria parasite to thrive. And it is here also that Plasmodium
falciparum the most deadly species of the malaria parasite is most
common. This fatal combination greatly increases the transmission
of malaria infection and the risk of disease and death. Second,
poverty and lack of good-quality health care have hindered the
control and treatment efforts that have had a significant impact
elsewhere in the world.

Those most affected

A single bite from an infected mosquito is all it takes. A small
child whose body is not yet able to fight the disease can be dead
within a day. Pregnant women are highly vulnerable too. So is
anyone whose defences are low as a result of poor health or who has
no immunity because they have never, or only rarely, been infected
with malaria. ...

Pregnant women who get malaria in some lower-risk areas are prone
to anaemia, premature delivery and stillbirth; in other higher-risk
areas they are more likely to suffer and die from anaemia and their
babies are likely to be born too small to survive their first year
of life. And all who fall sick -- with fever, headache and
exhaustion -- are less productive and lose income because of
absences from work or being too ill to plant and harvest crops. In
effect, malaria tightens the shackles of poverty in the households,
the communities and the nations where it holds sway.

We now have the tools

At the heart of the RBM approach is an understanding that malaria
may never be wiped out once and for all. But the disease can and
must be controlled.

The fight to control malaria demands an attack on two fronts:
protecting the vulnerable and treating the sick. And it is
essential that the measures used are affordable and sustainable so
that they can continue to work far into the future.

Sleeping under a mosquito net treated with insecticides that kill
mosquitoes or stop them from biting is powerful prevention against
malaria, as is spraying inside dwellings with insecticides that
leave a residue on walls. Special protection for pregnant women
using these insecticide-treated nets (ITNs) and intermittent
preventive treatment with antimalarial drugs given as part of
normal antenatal care can protect the mother and her unborn child.
Rapid treatment with effective antimalarial drugs for anyone
suspected of having malaria can save lives. And improved early
warning, detection and response to malaria epidemics can avert
catastrophe.

The World Malaria Report 2005 documents the substantial progress
that has been made in implementing these strategies on an
increasingly wider scale. And, although it is too early to measure
the precise impact of these efforts in terms of lives saved, there
is good reason to believe that real reductions in deaths and
disease will be achieved in the next few years. ...

Meeting the challenges in malaria control

The World Malaria Report 2005 also reveals the difficulties
involved in the battle against malaria and shows the steps that are
being taken to overcome them.

For example, drug resistance has been a serious obstacle to malaria
control. Chloroquine, the cheapest and most widely used
antimalarial drug, has lost its clinical effectiveness in most
parts of the world. But the next generation of antimalarial drugs
-- artemisinin-based combination therapies (ACTs) are highly
effective and life saving. Work is under way to make these new
drugs widely available, and more and more countries are changing
their national drug policies and adopting ACTs as the first choice
of treatment. However, while ACTs are available at between US$ 0.75
and US$ 2.75 per treatment, they are much more expensive than the
drugs that previously worked. The higher cost puts ACTs beyond the
reach of many of the households where the need is greatest. ...

Still, the formidable ability of the malaria parasite to develop
rapid resistance to new drugs, and of the mosquitoes to become
resistant to new insecticides, means that researching, developing
and manufacturing new drugs and insecticides will continue to be of
paramount importance. There is also now potential for an
antimalarial vaccine, although this has proven more complex and is
taking longer than expected.

Poverty is another major obstacle. One of the significant
breakthroughs of recent years has been the mounting evidence that
ITNs offer highly effective protection. But the effort to increase
the numbers of children sleeping under ITNs has been hampered by
the gap between what the nets cost and what families can and will
pay for them. Now prices are being pushed down by increasing
competition, cutting taxes and tariffs and distributing
free-of-charge nets to the poor and most vulnerable. At the same
time, demand is being increased by health education and marketing.
The RBM partners are also working to encourage companies,
especially in Africa, to manufacture the latest generation of
treated mosquito nets that have insecticidal properties woven into
the fabric and are longer-lasting. ...

The United Nations Decade to Roll Back Malaria 2001-2010

Malaria is a problem to which answers are available. The know-how,
the plans and the technologies are all in place. And they are
beginning to work. Just two things stand in the way of taking
treatment and prevention measures to scale: a shortage of funds and
a shortage of in-country capacity to put plans into action on the
ground. This is the decade to take action: the time is now.

WHO estimates that around US$ 3.2 billion each year is required to
finance effective malaria control worldwide. Governments in
malaria-affected countries are committed to increasing their own
resources for malaria control, and multilateral and bilateral
donors have helped to provide extra money. The Global Fund to Fight
AIDS, Tuberculosis and Malaria (GFATM) is also an important
international funding source. But still the funds available fall
far short of what is needed.

The drive to strengthen health systems, build organizational
capacity and improve the infrastructure for supply and delivery on
the ground in malaria-affected countries will also require
commitment and cooperation between the global community and the
local communities of people who live their lives under threat from
the disease. ...

The RBM Partnership was launched against a disease that was rapidly
gaining ground. The efforts made since then mean that this is no
longer true. But the World Malaria Report 2005 makes it clear that
fully reversing the trend is going to require more resources and
more hard work in the years to come.

In the words of Professor Jeffrey Sachs, Director of the Earth
Institute at Columbia University and Special Advisor to United
Nations Secretary-General Kofi Annan, "Comprehensive malaria
control is the lowest-hanging fruit on the planet. For just US$ 3
per person per year in the rich countries, it is possible to fund
the comprehensive control of malaria in Africa, ensuring universal
access to live-saving nets, effective medicines, and other control
measures. Millions of lives in the coming years can be saved, with
profound economic benefits as well. This is an historic bargain too
great to miss."

"When I learned that malaria kills so many people just because they
can't get simple medicine or a net to sleep under, I said, 'This is
not possible, we must do something'." Youssou N'Dour, Musician,
describing the motivation for Africa Live Roll Back Malaria
Concert, Dakar, 12-13 March 2005

Prevention and treatment... the interventions that work

Insecticide-treated nets

ITNs protect people sleeping under them from malaria because they
kill mosquitoes or prevent them from biting. Properly used, ITNs
can cut malaria transmission by up to 90% and reduce child deaths
from all causes by a fifth.

Protecting pregnant women

Intermittent preventive treatment a dose of an antimalarial
medication given twice during pregnancy can be administered to
pregnant women via antenatal clinics and can prevent malaria.
Sleeping under an ITN can further protect pregnant women and their
unborn children from the dangers of malaria.

Indoor residual spraying

Killing mosquitoes by spraying dwellings with insecticides that
leave a residue on walls is a highly effective method for stopping
the spread of malaria especially during epidemics and emergency
situations.

Pre-empting epidemics

Sudden malaria epidemics can be foreseen using technologies such as
weather forecasting and the regular collection of data from
epidemic-prone districts. Predicting and then rapidly responding to
epidemics can dramatically cut the number of cases.

Effective antimalarial drugs

Traditional antimalarial drugs have lost their clinical
effectiveness as parasitic resistance has grown. But new generation
artemisinin-based combination therapies (ACTs) are highly effective
and life-saving in all but the most advanced cases.

Home management

Prompt treatment at home can mean the difference between life and
death among people who live in rural areas and have limited access
to health facilities. Home management of malaria which involves
education and training of mothers and provision of prepackaged
high-quality medicines allows families to care for their own
children effectively.

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